NEW CONSUMER INTAKE FORM

PERSONAL INFORMATION
Your Name:
Today's Date:
Your Email:
Work Phone:
Home Phone:
Your Address: (Number, Street, City, State, Zip)	Number Street City, State Zip
Date of Birth :
Social Security Number:
ETHNICITY	GENDER
Asian/Pacific Islander American Indian/Alaskan African American Caucasian Hispanic Other Unknown	Female Male
LIVING SITUATION	ACCESSIBLE LIVING
Independent Institution Dependent w/Fam-Friends Assisted Living Homeless Unknown Other	Yes No
PLEASE INDICATE SERVICE(S) REQUESTED BY ORDER OF NEED (1 for primary, 2 for secondary, etc. List up to 4)
Benefits Education, Individual and Sysytems Advocacy
Personal Assistance
Housing
Independent Living Peer Support
Transitional Funding
Assistive Technology
Community Outreach
Information and Referral
Volunteer Opportunities
How did you hear about us?
MARITAL STATUS
Maried Divorced Separated	Widowed Other Single
EMERGENCY CONTACT INFORMATION
Emergency Contact's Name:
Emergency Contact's Address: (Number, Street, City, State, Zip)	Number Street City, State Zip
Emergency Contact's Phone:
Emergency Contact's Work Phone:
SOURCE OF INCOME
Private SSI SSDI	VA Other Other Type:
MEDICAL INFORMATION	MEDICAL NOTES
Medi-Cal Medicare Other Insurance	Please include any special information about your medical condition here.
APPOINTMENT
Please indicate the best time for a staff person to contact you to set an appointment:	Time (AM/PM)
Would you prefer an appointment in the morning or afternoon?	Morning Afternoon

*All sections require a response